Exploring the knowledge, attitudes, and perceptions of women of reproductive age towards fertility and elective oocyte cryopreservation for age-related fertility decline in the UK: a cross-sectional survey.

STUDY QUESTION: What are the knowledge, perceptions and attitudes towards fertility and elective oocyte cryopreservation (OC) for age-related fertility decline (ARFD) in women in the UK? SUMMARY ANSWER: Awareness of OC for ARFD has reportedly improved compared to studies carried out almost a decade ago, but inconsistencies in knowledge remain regarding the rate of miscarriage amongst specific age groups, the financial costs and optimal age to undergo OC for ARFD. WHAT IS KNOWN ALREADY: The age of first-time motherhood has increased amongst western societies, with many women of reproductive age underestimating the impact of age on fertility. Further understanding of women's awareness of their fertility, the options available to preserve it and the barriers for seeking treatment earlier are required in order to prevent the risk of involuntary childlessness. STUDY DESIGN, SIZE, DURATION: A hyperlink to a cross-sectional survey was posted on social media (Instagram) between 25 February 2021 and 11 March 2021. PARTICIPANTS/MATERIALS, SETTING, METHODS: Women from the general population aged 18-50 years were invited to complete the survey. MAIN RESULTS AND THE ROLE OF CHANCE: In total, 5482 women fulfilled the inclusion criteria and completed the survey. The mean age of participants was 35.0 years (SD 10.25; range 16-52). Three quarters (74.1%; n = 4055) disagreed or strongly disagreed they felt well informed regarding the options available to preserve their fertility, in case of a health-related problem or ARFD. The majority overestimated the risk of miscarriage in women aged ≥30 years old, with 14.5% correctly answering 20%, but underestimated the risks in women ≥40, as 20.1% correctly answered 40-50%. Three quarters (73.2%; n = 4007) reported an awareness of OC for ARFD and 65.8% (n = 3605) reported that they would consider undergoing the procedure. The number of women who considered OC for ARFD across age groups were as follows: 18-25 (8.3%; n = 300), 26-30 (35.8%; n = 1289), 31-35 (45.9%; n = 1654), 36-40 (9.6%; n = 347), 41-45 (0.3%; n = 13), and 46-50 (0.1%; n = 2). The majority of women (81.3%; n = 4443) underestimated the cost of a single cycle of OC for ARFD (<£5000). Furthermore, 10.4% (n = 566) believed a single cycle would be adequate enough to retrieve sufficient oocytes for cryopreservation. Approximately 11.0% (n = 599) believed OC for ARFD may pose significant health risks and affect future fertility. Less than half agreed or strongly agreed that the lack of awareness regarding OC for ARFD has impacted the likelihood of pursuing this method of fertility preservation further (41.4%; n = 2259). LIMITATIONS, REASONS FOR CAUTION: Results from cross-sectional studies are limited as interpretations made are merely associations and not of causal relationships. The online nature of participant recruitment is subject to selection bias, considering women with access to social media are often from higher socioeconomic and education backgrounds, thus limiting generalizability of the findings. WIDER IMPLICATIONS OF THE FINDINGS: Further education regarding the financial costs and optimal age to undergo elective OC to increase the chances of successful livebirth are required. Clinicians should encourage earlier fertility counselling to ensure that OC is deemed a preventative measure of ARFD, rather than an ultimate recourse to saving declining fertility. STUDY FUNDING/COMPETING INTEREST(S): No funding was required for this article. There are no conflicts of interests to declare. TRIAL REGISTRATION NUMBER: N/A.

Uterine transplantation: legal and regulatory implications in England.

Uterus transplantation (UTx) is fast evolving from an experimental to a clinical procedure, combining solid organ transplantation with assisted reproductive technology. The commencement of the first human uterus transplant trial in the United Kingdom leads us to examine and reflect upon the legal and regulatory aspects closely intertwined with UTx from the process of donation to potential implications for fertility treatment and the birth of the resultant child. As the world's first ephemeral transplant, the possibility of organ restitution requires consideration and is discussed herein. TWEETABLE ABSTRACT: Uterine transplantation warrants a closer look at the legal frameworks on fertility treatment and transplantation in England.

Uterine Transplantation: Scientific Impact Paper No. 65 April 2021.

A uterine transplant, or womb transplant, provides a potential treatment for women who cannot become pregnant or carry a pregnancy because they do not have a womb, or have a womb that is unable to maintain a pregnancy. This is estimated to affect one in 500 women. Options for those who wish to start a family include adoption and surrogacy, but these are associated with legal, cultural, ethical and religious implications that may not be appropriate for some women and their families. A womb transplant is undertaken when the woman is ready to start a family, and is removed following the completion of their family. Womb transplants have been performed all over the world, with more than 70 procedures carried out so far. At least 23 babies have been born as a result, demonstrating that womb transplants can work. While the procedure offers a different option to adoption and surrogacy, it is associated with significant risks, including multiple major surgeries and the need to take medications that help to dampen the immune system to prevent rejection of the womb. To date there has been a 30% risk of a transplant being unsuccessful. Although the number of transplants to date is still relatively small, the number being performed globally is growing, providing an opportunity to learn from the experience gained so far. This paper looks at the issues that have been encountered, which may arise at each step of the process, and proposes a framework for the future. However, long term follow-up of cases will be essential to draw reliable conclusions about any overall benefits of this procedure.

Anaesthetic considerations for fertility-sparing surgery and uterine transplantation.

A number of benign and malignant gynaecological conditions can cause infertility. Advancements in assisted reproductive technologies have facilitated the rapidly evolving subspecialty of fertility preservation. Regardless of clinical indication, women now have the reproductive autonomy to make fully informed decisions regarding their future fertility. In particular, there has been an increasing interest and demand among patients and healthcare professionals for fertility-sparing surgery. Gynaecologists find themselves continually adapting surgical techniques and introducing novel procedures to facilitate this rapidly emerging field and anaesthetists need to manage the consequent physiological demands intra-operatively. Not only is it important to understand the surgical procedures now undertaken, but also the intra-operative management in an ever evolving field. This article reviews the methods of fertility-sparing surgery and also describes important anaesthetic challenges including peri-operative care for women undergoing complex fertility-sparing surgeries such as uterus transplantation.

The vaginal microbiome in uterine transplantation.

Women with congenital absolute uterine factor infertility (AUFI) often need vaginal restoration to optimise sexual function. Given their lack of procreative ability, little consideration has previously been given to the resultant vaginal microbiome (VM). Uterine transplantation (UTx) now offers the opportunity to restore these women's reproductive potential. The structure of the VM is associated with clinical and reproductive implications that are intricately intertwined with the process of UTx. Consideration of how vaginal restoration methods impact VM is now warranted and assessment of the VM in future UTx procedures is essential to understand the interrelation of the VM and clinical and reproductive outcomes. TWEETABLE ABSTRACT: The vaginal microbiome has numerous implications for clinical and reproductive outcomes in the context of uterine transplantation.

Human uterine transplantation: a review of outcomes from the first 45 cases.

Uterine transplantation restores reproductive anatomy in women with absolute uterine factor infertility and allows the opportunity to conceive, experience gestation, and acquire motherhood. The number of cases being performed is increasing exponentially, with detailed outcomes from 45 cases, including nine live births, now available. In light of the data presented herein, including detailed surgical, immunosuppressive and obstetric outcomes, the feasibility of uterine transplantation is now difficult to refute. However, it is associated with significant risk with more than one-quarter of grafts removed because of complications, and one in ten donors suffering complications requiring surgical repair. TWEETABLE ABSTRACT: Uterine transplantation is feasible in women with uterine factor infertility, but is associated with significant risk of complication.

Anesthesia for Cesarean section in a patient with paraplegia resulting from tumour metastases to spinal cord.

PURPOSE: Spinal cord injured patients present multiple unique challenges to the anesthesiologist. These include choice of muscle relaxant and management of autonomic hyperreflexia. We report the anesthetic management for Cesarean delivery in a patient who was paraplegic due to spinal canal metastases. Preeclampsia and fever complicated this case. CLINICAL FEATURES: The patient presented at 29 wk gestation with progressive paraplegia at the T10 level due to metastatic osteosarcoma. She had a decompressive laminectomy without improvement in her paralysis. She subsequently developed preeclampsia at 31 wk gestation, and underwent Cesarean delivery for breech presentation under general anesthesia. Anatomical concerns left us unsure of the efficacy or safety of neuraxial anesthesia. CONCLUSIONS: Preeclampsia and autonomic hyperreflexia are generally indications for regional anesthesia for Cesarean section. Tumour in her spinal canal and laboratory abnormalities including thrombocytopenia and a potential urosepsis dissuaded us from this option. Additionally, rapid sequence induction and intubation were not preferred due to paraplegia, leading us to secure the airway fibreoptically.

An investigation into changes in lung function and the subjective medical benefits from breast reduction surgery.

The aim of this study was to assess the respiratory changes following reduction mammaplasty in women presenting for elective surgery; In addition, to assess whether these changes might be related to any symptomatic improvement. This was a prospective study examining women attending for breast reduction surgery over a 3-month period. Preoperative pulmonary function studies (PFTs) and a symptom questionnaire were completed before operation. These were repeated 6-8 weeks after surgery. Pulmonary function testing was carried out in all cases by the same operator. The study was carried out within a sub regional centre for plastic and reconstructive surgery. Local Ethics committee approval was obtained. Nineteen healthy women mean age 34.9 years and with a mean Body Mass Index of 27.62 were recruited. The mean weight of excised breast tissue was 1546 g. All preoperative pulmonary function tests were within normal limits. Six of the women smoked, none changed their smoking habits over the course of this study. Changes in pulmonary function studies were analysed using the paired t-test. A 'P' value of < 0.05 was considered to be significant. Seventeen women had a post operative improvement in PFTs. Statistically significant improvements were obtained for changes in peak expiratory flow rate (PEFR, P = 0.005) and peak inspiratory flow rate (PIFR, P < 0.0001). The 'P' values for changes in FEV1 (forced expired volume in 1 second) and FEV1/FVC (forced vital capacity) did not reach significance, whilst the 'P' value for the change in FVC was statistically significant (P = 0.01), although the actual mean change was small (0.07 litres). The study sample was too small to relate these changes to mass of excised tissue or BMI. All women taking part claimed an increased confidence and a cessation in analgesic use. Other reported benefits included an improved exercise tolerance (12/19), reduced sleep disturbance (4/19) and reduced breathing difficulties (1/19).

Analysis of the attention deficit in schizophrenia: a study of patients and their relatives in Ireland.

County Roscommon, a rural area in the western part of Ireland, was the site of a family study of schizophrenia. As part of this study, we have assessed several elements of attention, identified by principal components analysis in previous investigations, in a group of subjects with schizophrenia, first-degree relatives of subjects with schizophrenia and age- and education-matched controls. The schizophrenic subjects performed significantly more poorly than the controls; the performance of the relatives fell somewhere between the other two groups. Those relatives with a DSM-III-R diagnosis (most frequently, alcohol abuse or an affective disorder) tended to perform more poorly on some of the attention elements than relatives without a diagnosis; in contrast, control subjects with diagnoses were not distinguishable from other controls. The attention elements appeared to differ in their capacity to differentiate the groups and each seemed to have a distinctive profile. The effects of alcohol abuse were also considered. The results obtained with this cohort may provide clues concerning the pathophysiological basis of schizophrenia and the heterogeneity of its expression.

Comparing the efficacy of cisapride and ranitidine in oesophagitis: a double-blind, parallel group study in general practice.

Patients with endoscopically confirmed oesophagitis (n = 49) were treated for 8 weeks with either cisapride (10 mg four times a day) or ranitidine (150 mg twice a day) in a double-blind study in general practice. Mean overall symptom scores fell from 10.8 to 4.5 in the cisapride group and from 9.9 to 4.4 in the ranitidine group over the course of the study. The proportion of patients reporting improvements in individual symptoms in the two treatment groups (cisapride and ranitidine respectively) were: heartburn, 66% and 55%; acid regurgitation, 53% and 47%; epigastric pain, 60% and 52%; satiety, 57% and 47%; bloating, 69% and 71%; belching, 65% and 72%; nausea, 62% and 85%; vomiting, 77% and 66%; poor appetite, 50% and 75%. Improvement in the endoscopic grade of oesophagitis was observed in 66% of patients receiving cisapride and 63% of those receiving ranitidine. It was concluded that cisapride is as effective as ranitidine in relieving the symptoms of oesophagitis and in healing oesophageal erosions.

Repression: the evolution of a psychoanalytic concept from the 1890's to the 1990's.

The author presents a summary of Freud's concept of repression, including modifications of the concept from 1894 to 1932. Several more recent treatments are examined, including those of Piaget; Rosenblatt and Thickstun; Galin; Kissin; Shapiro and Perry; Schwartz; the cognitive and experimental psychologists, including Kihlstrom and Erdelyi; the "connectionists"; and Edelman. Finally, the author delineates several different types of repression, outlining how the different models might apply to the different types of repression.

On familial factors in the attentional deficit in schizophrenia: a review and report of two new subject samples.

We review the literature on attentional impairment in schizophrenics and their first-degree relatives and present new information from ongoing family studies of the disorder in Ireland and Israel. Subjects were administered a neuropsychological test battery (the NIMH Attention Battery) intended to measure four different elements of attention: encode, focus/execute, sustain, and shift. Results from both samples indicated that schizophrenic subjects performed most poorly on the tests, the control subjects performed best, and the scores of the relatives fell somewhere between the other two groups. Separation among subject groups was most significant for those tests comprising the focus/execute and sustain elements. Some of the results indicate, as well, that tests of auditory sustained attention may be the most discriminating of all. Overall comparison of the Irish and Israeli cohorts revealed striking differences. While within cohort differences remained, subjects from the Irish sample performed more poorly on many of the tests than Israeli subjects. This between-cohort difference was not found in the sustain element, as measured by the Continuous Performance Test. The socio-cultural implications of these findings are discussed with respect to future neuropsychological studies of schizophrenia.

Cognition in eating disorders.

Cognitive functions were investigated in four groups of women: 30 underweight anorexics, 38 normal-weight bulimics, 20 long-term weight-restored anorexics, and 39 normal controls. A MANOVA was used to examine performance on five neuropsychological domains derived from prior principal components analyses of a comprehensive neuropsychological battery. Underweight anorexics performed more poorly than normal controls in four of five neuropsychological domains (focusing/execution, verbal, memory, and visuospatial), while normal-weight bulimics showed poorer performances only in focusing/execution. The absolute differences in scores between eating disorder groups and normal controls were for the most part small, suggesting subtle rather than frank cognitive difficulties. Poorer neuropsychological test performance was associated with anxiety but not depression as measured by the Tryon, Stein, and Chu Tension scale and scale 2 of the MMPI respectively. The findings support previous reports of attentional difficulties in eating disorders but do not support the hypothesis of differential right-hemisphere dysfunction in eating disorders.